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High impact actions for service improvement and delivery by Transforming Care Partnerships
England
Health Education England
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Guidance
High impact actions for service improvement and delivery by Transforming Care Partnerships
NHS England, Learning Disability Programme
28 November 2016
Transforming Care Partnerships, CCG Clinical Leaders, CCG Accountable Officers, CSU Managing Directors, Care Trust CEs, Foundation Trust CEs, Medical Directors, Directors of Nursing, Local Authority CEs, Directors of Adult SSs, NHS England Regional Directors, NHS England Directors of Commissioning Operations, Allied Health Professionals, GPs, Communications Leads, Directors of Children’s Services, NHS Trust CEs.
CCG Accountable Officers, NHS England Regional Directors, NHS England Directors of Commissioning Operations, All NHS England Employees.
These high impact actions are intended to be complementary to the work on new models of care that is already underway and support Transforming Care Partnerships (TCPs) to go further and faster by providing a focus for every member of the team to play their part to ensure their local care system is working effectively.
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NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE
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Equality and Health Inequalities StatementPromoting equality and addressing health inequalities are at the heart of NHS England’s values. Throughout the development of the policies and processes cited in this document, we have:
• Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and
• Given regard to the need to reduce inequalities between patients in, access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.
Building the Right Support is a national plan to develop community services and close inpatient facilities for people with learning disability and/or autism who display behaviour that challenges, including those with a mental health condition.
Children, young people and adults with a learning disability and/or autism have the right to the same opportunities as anyone else to live satisfying and valued lives and to be treated with dignity and respect. They should have a home within their community, be able to develop and maintain relationships, and get the support they need to live healthy, safe and rewarding lives.
Building the Right Support describes a range of services and support that should be in place within any local area for people with a learning disability and/or autism. These high impact actions are intended to be complementary to the work on new models of care that is already underway and support Transforming Care Partnerships (TCPs) to go further and faster by providing a focus for every member of the team to play their part to ensure their local care system is working effectively.
These high impact actions are centred on the individual and can help TCPs make the biggest strides forward, in supporting children, young people and adults to have a home within their community, be able to develop and maintain relationships, and get the support they need to live healthy, safe and rewarding lives – thereby reducing the numbers of people in inpatient settings.
In delivering these high impact actions, planning and governance should be through a process of co-production, including those people with direct experience of services and their families, as well as wider system partners (e.g. children’s services, care providers and criminal justice system agencies), at both an individual and strategic level.
These high impact actions are an invaluable source of ideas to achieve change. However, we know identifying what is possible is the easy part with the real challenges being in the implementation. That is why a range of practical support is available to help you.
High impact actions for service improvement and delivery by Transforming Care Partnerships
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ACTION
Know the local transforming care population through the development of a dynamic register, enabling local services to anticipate and meet needs and plan strategically.
Develop and implement an ‘at risk of admission register’ for those people most at risk of admission - see the Care and Treatment Review (CTR) policy to ensure the right support is provided to enable people to stay at home.
IMPACT
Sustaining individuals to live in the community through appropriate strategic planning and early intervention.
Prevention of crisis and reduction in hospital admission.
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ACTION
Develop and embed person-centred approaches that enable children, young people, adults and those closest to them to be at the centre of their own care and support arrangements - e.g. in the development and implementation of their person-centred care and support plans and Education, Health and Care (EHC) plans, including through the proactive use of personal/integrated budgets.
IMPACT
Sustainable, person-centred solutions that meet the needs of individuals.
A shift in power from services to individuals.
Community-based solutions, including greater access to universal services.
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ACTION
Support the delivery of personal health budgets, personal budgets and integrated budgets, working with teams that have experience of doing this e.g. Continuing Health Care teams.
IMPACT
Increased uptake of personal/integrated budgets.
Choice and control for individuals.
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High impact actions for service improvement and delivery by Transforming Care Partnerships
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High impact actions for service improvement and delivery by Transforming Care Partnerships
ACTION
Ensure strong health and social care involvement and active participation in education health and care plans for children and young people with a learning disability and/or autism, delivering clear, aspirational, practice-based and lifelong pathways for children and young people into adulthood.
IMPACT
Reduction of behaviours that challenge and improved well-being of children and their families.
Prevention of institutional placements in the future, particularly those that are at a distance from home, delivering savings in long term care costs.
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ACTION
Identify the total financial and staffing resourcesacross health and social care (adult andchildren’s) for Transforming Care, and work collaboratively across the partnership tomaximise and shift resources to where they will make the biggest positive difference in delivering transformation.
The TCP should collaborate and work with the Sustainability and Transformation Plan (STP) to ensure that sufficient resources and support for learning disability is identified and included in the STPs plans.
IMPACT
Remove barriers created by silo funding arrangements.
Enable closer working across the system to mitigate financial risk.
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ACTION
Undertake work to understand the capacity and skill mix of current and potential future health and social care providers and complete a gap analysis, to be included in local market position statements (including those coming through transition); to enable the robust development of community services to take place.
Establish and work with a group of preferred providers to meet the identified needs of current and future demand. For those on the register with offending behaviour it is essential to identify providers who can manage high levels of risk and keep the person and the community safe.
IMPACT
A robust care market able to meet the needs and provide high quality of care for people whose behaviours challenge. Thereby providing choice and control for individuals.
Enable those who have been involved with the criminal justice system and approaching discharge to live safely within the community, reduce reoffending and subsequent bed use.
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ACTION
Develop high quality intensive 24/7 multidisciplinary health and social care support in the community for the individual, their family and paid carers.
IMPACT
People remain in their own home, resulting in a reduction in hospital admissions.
Prevention of crisis.
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ACTION
Undertake a capacity and gap analysis of current housing need and work proactively with housing partners to develop and deliver housing opportunities and options for current and future demand, centred on the specific housing needs of the individual.
Plan the decommissioning of beds to ensure patient safety at all times as the number of in-patient services decrease.
IMPACT
A robust housing market able to meet the needs of people whose behaviours challenge.
Choice and control for individuals.
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ACTION
Continue to use the robust process of the CTR (community/hospital/post admission) and act on the CTR recommendations. Implement the blue light protocol, and ensure named senior leadership and oversight to reduce admissions and placements out of area (e.g. 52 week placements and out of area residential placements).
IMPACT
Hospital placement is only when clinical treatment is required and cannot be administered at home or in a community setting, preventing avoidable admissions.
Prevention of inappropriate out of area educational and residential placements.
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High impact actions for service improvement and delivery by Transforming Care Partnerships
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Find out more:www.england.nhs.uk/learningdisabilities
ACTION
Where an admission to hospital is necessary, ensure there are clearly defined intended outcomes for admission, that discharge planning starts immediately (using the discharge standards), and that the individual is supported to be involved and understand their discharge pathway.
Where a pre-admission CTR has not taken place, ensure a post-admission CTR takes place within two weeks of admission.
IMPACT
A well planned and timely discharge, reducing length of stay in hospital.
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High impact actions for service improvement and delivery by Transforming Care Partnerships
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